GEAR UP Wyoming Application - Eastern Wyoming College - Eastern Wyoming College

WISER #*

Current Grade Level in School*

School Name

Name*

First

Middle

Last

Address*

Street Address

Address Line 2

City

State

ZIP Code

Home Phone*

Student Cell Phone

Student Email*

Enter Email

Confirm Email

Can we text of email you with information on GEAR UP?*

Yes
No

Gender Identity*

Male
Female
Other
Prefer Not to Say

Date of Birth*

Anticipated Graduation Date*

Ethnicity/Race

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Race and/or Ethnicity Unknown
Prefer Not to Say

Do you participate in an English Language Learner (ELL/ESL) program?*

Yes
No

Are you currently on an Individualized Education Plan (IEP)?*

Yes
No

Are you currently in foster care?*

Yes
No

Are you currently experiencing homelessness?*

Yes
No

Primary Language Spoken in Home?*

Guardian Contact Information #1

Name

First

Last

Relationship

Home/Cell Phone Number

Work Phone Number

Email

Enter Email

Confirm Email

Address

Street Address

Address Line 2

City

State

ZIP Code

Guardian Contact Information #2

Name

First

Last

Relationship

Home/Cell Phone Number

Work Phone Number

Email

Enter Email

Confirm Email

Address

Street Address

Address Line 2

City

State

ZIP Code

Do you participate in Upward Bound, Educational Opportunity Centers, or Educational Talent Search?

Yes
No

I authorize the release of my confidential student information (including via fax and email), which may include, but is not limited to, contact information, secondary and post-secondary academic transcripts, college scholarships, financial aid award information from post-secondary institutions, IEPs, standardized test scores, and free/reduced lunch status to GEAR UP Wyoming staff. I also understand that this information may be used by GEAR UP Wyoming staff for the purpose of referral to
other state/federal educational programs and services for which I am likely to be eligible, including college-level student success services.

Student Signature*

Date*

I, as the guardian, authorize the release of the information described above as required for the student to receive GEAR UP Wyoming services and participate
in program activities. To the best of my knowledge, I certify that the above student and guardian information is true and correct.

Guardian Signature*

Date*

Photographs and videos may be taken of GEAR UP Wyoming participants during activities and may be used for promotional purposes. All photographs and
videos are property of GEAR UP Wyoming. All photographs and videos are property of GEAR UP Wyoming. If you do not want photographs or videos of yourself or your student publicized, please initial:

Initials

GEAR UP Wyoming is funded through a grant from the U.S. Department of Education totaling $3,430,000 annually, with an additional $3,430,000 annually provided by in-kind and scholarship contributions. GEAR UP Wyoming is a project of Student Educational Opportunity, a unit within the Division of Academic Affairs at the University of Wyoming. Revised 8.23.2019 – 2017-2024 Grant